1 / 27

Top 3 Articles That Changed My Approach to EOS

Explore groundbreaking articles on kyphosis, pulmonary outcomes, and T1-12 length impacting early-onset spine deformities. Discover key insights from ICEOS Warsaw 2014 and innovative solutions presented by leading experts in the field. Uncover the complexities of non-flexible kyphosis and major causes of anchor failure, redefining treatment strategies for optimal patient outcomes.

cecilg
Download Presentation

Top 3 Articles That Changed My Approach to EOS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Top 3 Articles That Changed My Approach to EOS Top 10 List = too long Kyphosis Kyphosis Pulmonary Outcome & T1-12 Length

  2. Kyphosis and Early-onset Spine Deformity (EOSD) A Problem Seeking a Solution ?? C.E. Johnston MD ICEOS Warsaw 2014 Disclosures : Medtronic (research support, financial support/other) Elsevier (financial)

  3. Non-flexible Kyphosis – Major Cause of Proximal Anchor Failure Schroerlucke et al (GSSG), 2012 Spine 90 pts, f/u 5-7yr complic*/ #pts K- <10o thor kyph 12/26 N 10-40o 16/35 K+ >40o 34/29 *- implant related • Infection rate: K+ 28% N 2.8% K- 12%

  4. Implant complications vs preop th kyph Survival curve

  5. Proximal Anchor Failure / KyphosisWhat about VEPTR ? Reinkeret al: Can Veptr Control Progression of Early-onset Kyphoscoliosis ?CORR 2011 14 pts, 5.8 yr f/u Selection : rx plan altered to specifically treat problematic thoracic kyphosis ….normal kyphosis initially, hyperkyphosis during rx

  6. Reinker et al, 2011 • T2-12 mean kyph 68o 91o @ f/u • No change in T1-5… partial p.j.k. problem • Scoliosis curves not improved (3-16 expansions) • Thoracic length increase 2.6 cm (-1 – 7.5) • 7/14 req’d revision of proximal cradle • Cradle below 3rd rib • Insufficient distal anchor point ( above L3) • Rib-rib constructs ineffective …..extend to pelvis if possible, 2nd device on opposite side

  7. PJK w/ VEPTR Distracting upper Th ribs doesn’t necessarily move upper Th spine congruently, creates +ve sagittal balance subsidence

  8. Flatback 2o repeated distractions (esp. with pelvic anchors in ambulatory patients JT Smith, Bilateral Rib-to-Pelvis Technique. CORR 469, 2011 9/05 8/96

  9. Kyphosis– biomechanically not good for distraction-based methods • Posterior pull-off forces large (use wires above) • Cantilever plowing (screws) possible - ? Hooks/wires better? • Distraction creates kyphosis • Rod contour can become inappropriate as lengthening proceeds, worsens as more kyphosis occurs

  10. Anti-kyphosis construct – match radius of curvature of 2 rod segments to sagittal plane “Veptr” concept Exacerbated by distraction of L-S segments -> +vesagittal balance

  11. 5 yo congenital myopathy ROS benign, no significant respiratory episodes x 4 yr Pft unable to obtain Sat 99% RA, RR 14

  12. traction Initial xrays

  13. Ideal growing rod candidate ?Anti-kyphosis construct proximally • Fuse proximal anchors @ initial procedure – minimal distraction • Dominoes proximal (rod contour issue during lengthening) • Sublaminar backup for upper claw

  14. Last f/u before fusion age 111 broken rod revision, T1-12 = 28 cm

  15. Non-flexible Kyphosis – Major Cause of Proximal Anchor Failure What’s Changed ? • Preop HGT to decrease deformity (Emans SRS 07) • Instrument into cervical lordosis (not chest wall) • Fuse upper anchors first, include T1-4/5 prn, then distract for correction @ 1st lengthening (not chest wall)

  16. Preop Traction x 2mo Lengthen x4

  17. Over-interpretation of Karol et al Worst PFT’s at f/u were in patients fused to T1-2……but all were fused T1/2 –> low Th or L levels = entire T spine up to T1/2

  18. Are we sure we know what we’re doing? JBJS 96-A ; Aug 2014

  19. Dede, Motoyama et al JBJS 2014 Pulmonary and radiographic outcomes of VEPTR Age 4.8 yr /11 expansions/ 6 yr f/u T1-12=14.9 cm ……NOT NEARLY ENOUGH (Karol et al JBJS ‘08)

  20. Dede, Motoyama et al JBJS 2014 Pulmonary and radiographic outcomes of VEPTR • Th kyphosis (57 -> 66 all patients) • +ve sagittal imbalance • high Th kyphosis • Inverse correlation between hyperkyphosis and FVC %pred • Similar outcomes reported by Reinker and Lattig • Counterpoint – most severely involved congenital spine/chest wall cases

  21. TSRH GR “Graduates” paper #20 T1-12cmMTdeg Preop 13.9 98 Last surg 22.8 48 Last f/u 23.9 42 Complication (rod/anchor): 7 in 4 patients PFT 1st(6+9)f/u(13+0) FEV1 (L) .71 1.45 FEV1 (%) 61 46.5 FVC (L) .75 1.73 FVC (%) 62 49 Conclusions: in spite of what appears to be satisfactory thoracic length gain and curve correction during 7 year of surgical management with acceptable complication rate, pulmonary outcomes are diminished by % pred outcomes criteria.

  22. Have pulmonary outcomes affected my practice ? • Surgical lengthening and expansions worrisome lack of “improvement” • Re-assessment of early intervention in favor of delaying tactics • Emphasizes lack of clinically important outcome data re TIS and natural hx, especially severe congenital cases

  23. 2 y.o. male w/ J-L Start rxasap? Mother age 22 – no rx Asymptomatic T1-12 = 18.1 cm Grandmother age 49 – no rx Respiratory sx - ? Age, BMI T1-12 = 18.7 cm

  24. Sagittal plane (kyphosis) problems –> use HGT + fuse in prox anchors before start • More severe chest wall deformities (rib anchors): • Constant surveillance for kyphosis • Better nat’lhx info before start • Avoid ineffective serial surgeries

  25. Initial Rx – Traction x 2 mos.

More Related